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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Sexually Transmitted Infections Key Feature 4: In high-risk patients who are symptomatic for STIs, provide treatment before confirmation by laboratory results. Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 5a: In a patient requesting STI testing: Identify the reason(s) for requesting testing. Skill: Clinical Reasoning, Patient Centered Phase: Hypothesis generation, Treatment Key Feature 5b: In a patient requesting STI testing: Assess the patient’s risk. Skill: Clinical Reasoning, Patient Centered Phase: History, Diagnosis Key Feature 5c: In a patient requesting STI testing: Provide counselling appropriate to the risk (i.e., human immunodeficiency virus [HIV] infection risk, non-HIV risk). Skill: Clinical Reasoning, Patient Centered Phase: Diagnosis, Treatment Key Feature 6: In a patient with a confirmed STI, initiate:
Phase: Treatment, Follow-up Key Feature 7: Use appropriate techniques for collecting specimens. Skill: Psychomotor Skills/Procedure Skills, Clinical Reasoning Phase: Investigation, Physical Key Feature 8: Given a clinical scenario that is strongly suspicious for an STI and a negative test result, do not exclude the diagnosis of an STI (i.e., because of sensitivity and specificity problems or other test limitations). Skill: Selectivity, Clinical Reasoning Phase: Diagnosis, Investigation Vaginitis Key Feature 1: In patients with recurrent symptoms of vaginal discharge and/or perineal itching, have a broad differential diagnosis (ex: lichen sclerosus et atrophicus, vulvar cancer, contact dermatitis, colovaginal fistula), take a detailed history, and perform a careful physical examination to ensure appropriate investigation or treatment. (Do not assume that the symptoms indicate just a yeast infection.) Skill: Clinical Reasoning Phase: Hypothesis generation, Physical Key Feature 2: In patients with recurrent vaginal discharge, no worrisome features on history or physical examination, and negative tests, make a positive diagnosis of physiologic discharge and communicate it to the patient to avoid recurrent consultation, inappropriate treatment, and investigation in the future. Skill: Clinical Reasoning Phase: Diagnosis Key Feature 3: When bacterial vaginosis and candidal infections are identified through routine vaginal swab or Pap testing, ask about symptoms and provide treatment only when it is appropriate. Skill: Clinical Reasoning, Selectivity Phase: History, Treatment Key Feature 4: In a child with a vaginal discharge, rule out sexually transmitted infections and foreign bodies. (Do not assume that the child has a yeast infection.) Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Diagnosis Key Feature 5: In a child with a candidal infection, look for underlying illness (ex: immunocompromise, diabetes). Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis In the last month or so I have encountered at least 4 different females with varying presentations of vaginal discharge, pruritus, and perianal itching. The synopsis of their presentations were as follows:
Vaginal and perianal pruritus/discomfort and/or discharge can occur for a variety of reasons, and given that patients are often vague when discussing such symptoms for various reasons (ex: shy/embarrassed, not familiar with terminology to describe symptoms, only saying one of a cluster of symptoms), it is important to consider a wide differential when a patient presents with vaginal or perianal pruritus/discomfort and/or discharge. Although candida vulvovaginitis is one of the most common causes of vulvovaginal itching and discharge, and the presence of vaginal itch and white clumpy discharge is almost always indicative of a yeast infection, it's still important to make sure there isn't something else more ominous going on (such as a sexually transmitted infection that could become invasive with serious repercussions to fertility and life) before defaulting to this easy and sometimes incorrect assumption.** My general DDx for genital discharge/pruritus is as follows:
So there are lots of possible reasons for genital discharge/pruritus. Despite this, history +/- physical examination can significantly reduce the likelihood of many of the options. It's important to obtain a history of risk factors for the various possibilities that includes:
A history can be quite convincing of a specific etiology, and the physical examination can be high yield in further narrowing the differential. In general, it may be helpful to consider performing an abdominal exam, a digital rectal exam (if anal condylomata are present to rule out rectal malignancy), and a pelvic/genital exam. Investigations to consider include:
Treatment will depend on the etiology, and may include antimicrobials for infectious etiologies, surgical correction for structural concerns, and avoidance of any chemical irritants in the setting of contact dermatitis. Some sexually transmitted diseases require public health notification. See this link for the list of reportable diseases in BC. If a patient's concern is that of vaginal discharge without associated features of disease or risk factors on history, and if physical examination and investigations find no evidence of disease, the discharge could be normal physiological discharge. This is a diagnosis of exclusion, however, as it is important not to miss a diagnosis that could progress and have serious and irreversible consequences (such as pelvic inflammatory disease from a sexually transmitted infection). *When I first spoke with this patient who came requesting an STI test, I first of all said absolutely so that she would know that at anytime she is welcome to come into the clinic for STI testing. I then asked her if it was okay with her that I ask her a few questions just in terms of assessing her risk for transmissible infections. I asked her why she wanted to get STI testing. She endorsed having unprotected sex within the last few weeks, and with this new discharge, she was naturally concerned and requesting STI testing. She had been with the partner for a few weeks and had not had another sexual partner for months. She believed they both hadn't had any other partners since acquainting, and that he hadn't had any partners for some time as well. She was not aware of any STIs on his end. She denied a history of street drugs, denied any sex work, and thought that her partner had not been involved with street drugs or sex work either. She was also fairly confident that he did not engage in sexual acts with men. These were all questions to try to estimate not only her risk of having an STI, but also of acquiring HIV, which can be transmitted via shared drug paraphernalia or sexual activity, and with greater risk of transmission in this way when co-transmitted with an STI, which her discharge could've been a manifestation of. According to my history, her risk of having HIV at this time was low. A first-catch dirty urine NAAT screen for chlamydia and gonorrhea has high sensitivity, but does not provide an antimicrobial sensitivity profile, while a swab of discharge for culture and sensitivity does. So, in the presence of genital discharge, obtaining a sample of the discharge (be it via a vaginal self-swab or endocervical swab) is preferable. The patient's Pap test happened to not be up to date, and so we did a double whammy: a speculum exam during which I was able to assess the character of the discharge and look for other abnormalities along with gathering my Pap smear and microbial specimens. Her vaginal discharge appeared white and clumpy, suggesting a diagnosis of vaginal candidiasis as I knew from history that she had associated vaginal pruritus (pruritic vaginitis and clumpy white discharge almost always means vaginal candidiasis). However, with her sexual history putting her at risk for an STI, and knowing there could be more than one thing going on, we sent swabs off for microbial testing to rule out an STI and confirm yeast, and we gave her a prescription for fluconazole to be taken empirically, given the high pre-test probability, the fact that she was bothered by her symptoms, and the fact that this treatment has minimal side effects. If the discharge did not have the classic yeast appearance, or if she was not complaining of significant pruritus, or if she was not reliable to follow up, I would have considered treating her empirically for chlamydia and gonorrhea as well. These highly transmissible STIs need to be treated to avoid spread and prevent complications such as infertility, and generally the risk of over-treating STIs outweighs the risk of under-treating them. The regimen for this is azithromycin 1g PO x 1 dose and ceftriaxone 250 mg IM x 1 dose. If I had felt this patient was at risk of HIV, I would've also tested for this, and probably for syphilis as well. If there was a history of IVDU, I may have also tested for viral hepatitis. If you think a patient has an STI and are awaiting confirmation, it's also a time when counseling about safe sexual practices and possibly contraception is indicated. In the time while awaiting results of STI testing, patients should also abstain from further sexual activity or at least have protected sex if engaging in sexual activity prior to receiving confirmation of the test results. If testing for HIV, it's important that patients understand that there can be up to a 3 month window period from the last risky behaviour and a test that shows HIV positivity, so repeat testing is strongly advised if not more than 3 months out from the most recent risky behaviour. With challenging patients, it's particularly important to try to create a safe space and build rapport to keep patients engaged in care. If the results of an STI test are positive, all fo the patient's sexual partners who could've have also come into contact with the STI must be treated empirically, with the same regimen listed above. STIs are notifiable infectious diseases, and mandatory reporting to Public Health must be done. Public Health then performs contact tracing and notification, in efforts to minimise the risk of further transmission. It is important to notify patients about the legality of this, so they have the opportunity to contact others in advance. If this patient had instead presented for her screening Pap test and had not been complaining of vaginal discharge or pruritus, if I noticed abnormal discharge on examination (ex: white clumpy discharge suggestive of yeast, or an off-white, thin, and homogeneous "fishy smelling" discharge that could be suggestive of bacterial vaginosis), asking about symptoms and risk factors for an infectious etiology would be warranted. But it's also important to recognize that if the patient is asymptomatic, there aren't any risk factors, and the discharge isn't grossly abnormal, this may be the patient's normal variant physiologic discharge, and no investigation or treatment may be indicated. I say this because many females come to the family doctor's office to get a "Pap test" thinking this is the same thing as an STI test. It is not. The Pap test takes a sample of endocervical cells to screen for cervical cancer, and that is all. My general practice, instead of inquiring retroactively, is to ask in advance of doing the Pap test if the patient is also interested in STI screening/testing. If the patient says that indeed they do want STI testing, I probe a bit and ask a few questions to assess risk (was a barrier method used, who were the partner(s), patient's past history of having an STI, etc.). If there is a history that suggests there is a risk of STI, then I collect swabs if the patient is okay with it while I am performing the Pap. The patient always has the option to decline, and I always make sure to let her know that she can return at any time either way for STI testing in the future. **In the setting of a child who presents with vaginal discharge, although it is possible also that she has vaginal candidiasis (particularly if the child wears diapers, is immunosuppressed, or has had recent antibiotic therapy), it is always important to collect swabs to confirm yeast (vaginal candidiasis is clinically overdiagnosed per the UpToDate article, Overview of vulvovaginal complaints in the prepubertal child (2018)) and rule out other pathogens, such as a sexually transmitted infection. Although the history may not suggest it, it is important that all physicians recognize this possibility and collect swabs for microbial testing just in case. The repercussions of omitting this could be unforgivable, perhaps the only clue that the child has sustained sexual abuse. That being said, the discharge is more likely to be a consequence of yeast infection. If this is a sporadic and isolated occurrence, particularly if there are known precipitants on history such as recent antibiotic therapy, then this would warrant antifungal therapy without further investigations. If there are no known precipitants or the child has recurrent episodes of vulvovaginal candidiasis after it has been eradicated, it is important to consider why this is happening. The child may be immunocompromised, such as from HIV infection or diabetes mellitus. These would be important not to miss. It would be important to do a comprehensive history and physical exam to look for any symptoms or signs suggestive of underlying disease, and consider referring the child to a gynaecologist or infectious disease specialist. In the menarchal female, vaginal yeast infections are common, and by themselves would not warrant an extensive clinical assessment. However, if the menarchal female has >3 episodes per year, this too may warrant referral as clinically indicated to a gynaecologist or infectious disease specialist, as it is possible this patient also has an underlying reason for what would otherwise be a benign infection.
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